Tywan Ajani, LCSW, M.Ed.
Robert Stempel College of Public Health and Social Work, Florida International University, United States.
Corresponding Author Details: Tywan Ajani, LCSW, M.Ed., Robert Stempel College of Public Health and Social Work, Florida International University, United States.
Received date: 20th July, 2023
Accepted date: 24th August, 2023
Published date: 26th August, 2023
Citation: Ajani, T., (2023). Interventions Addressing Black/African American Adults Affected by Adverse Childhood Experiences (ACEs): A Scoping Review. J Ment Health Soc Behav 5(2):181.
Copyright: ©2023, This is an open-access article distributed under the terms of the Creative Commons Attribution License 4.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
Objective: The aim of this scoping review was to provide an overview of the literature on interventions to mitigate the negative impacts of adverse childhood experiences (ACEs) among Black/ African American adults. The specific objectives were to qualitatively examine, compare, and contrast the literature; to provide a narrative summary of each intervention identified in the search; and to identify gaps in the literature.
Introduction: ACEs have been identified as a significant public health problem due to their destructive nature on a person's subsequent adult life course. Among the three largest racial/ethnic groups in the United States (White/Caucasian, Black/African American, and Hispanic American), the Black/African American community suffers the highest incidence of ACEs. However, there is a paucity of research examining interventions specifically for Black/African American adults suffering from the negative impacts of ACEs.
Inclusion criteria: This study only included published material from the United States within the past ten years. Studies included must have had at least 25% of participants identified as Black/African American adults. The study had to entail an intervention directly applied with the identified population targeting an ACE-related outcome.
Methods: The literature search was conducted between December 2022 and January 2023 using the Social Work Abstracts, PsychInfo, Applied Social Sciences Index and Abstracts (ASSIA), and the Social Services Abstracts. Data were extracted on author(s) name, year of publication, the type of intervention, the sample demographics (i.e. age, race, and location), the purpose of the study, the reported outcomes, and the results. Results were summarized in tabular and narrative forms.
Results: The search identified 1,146 relevant studies according to the search criteria. Of these, 784 were screened as meeting all or some of the inclusion criteria. The final assessment left 6 studies as fully meeting all the inclusion criteria. Overall, the analysis found that psychosocial and psychoeducation-based interventions positively affected the reduction of ACE-related symptoms. Nevertheless, it is difficult to develop intervention themes as there is tremendous variation in the intervention designs, execution, location, and methods. Additionally, only two of the studies were randomized control trials (RCTs), thus limiting overall methodological rigor.
Conclusions: This study highlights the limited evidence of interventions specifically addressing this population. The evidence suggests a positive impact of the interventions on the ACE symptoms identified. However, the rigor of the few existing studies is limited. The Black/African American community will benefit from the development of RCTs on culturally appropriate interventions to combat the damaging effects of adverse childhood experiences.
Adverse childhood experiences (ACEs) are potentially traumatic events occurring in childhood, such as being a victim of child abuse or neglect or living in a household where there is substance abuse, mental illness, incarceration, or parental separation/divorce (CDC, 2022). ACEs have been identified as a significant public health problem due to their destructive nature on a person's subsequent adult life course [1]. Strong evidence supports the impact of ACEs across the life course [2]. ACEs are linked to risky health behaviors such as tobacco use, alcohol and other substance misuse, and unprotected sex, which increases risk for depression, heart disease, cancer, substance use disorders, and ultimately, premature mortality. ACEs also affect economic life potential, such as academic achievement, employment, and wealth. The impact of ACEs is not only detrimental to individuals but also to entire racial/ethnic communities and society as a whole. ACEs have a visible, negative impact on the economy, costing hundreds of billions of dollars in economic loss in wages and taxes as well as in health costs for treatment and prevention efforts [3].
Nationally, 61% of all U.S. adults have experienced at least one ACE [4]. Among the three largest racial/ethnic groups in the United States (White/Caucasian, Black/African American, and Hispanic American), the Black/African American community suffers the highest incidence of ACEs [1]. Black/African Americans are four times more likely to experience four or more ACEs than white Americans [4]. This social trajectory is significant as a higher number of ACEs are associated with greater negative impacts [5]. Furthermore, ACE exposure is more prevalent among Black/African Americans living in or growing up in impoverished neighborhoods. People from these communities often experience a vicious cycle of poverty and ACEs that keeps them trapped or limited in opportunities to advance economically. This cycle is often multi-generational [6].
However, despite the disproportionate incidence of ACES among the Black/African American population, there is a paucity of research examining interventions specifically for Black/African American adults suffering from the negative impacts of ACEs. This is the first study to provide a scoping review of interventions for this population. The purpose of a scoping review is to map the body of literature on a topic area or with a specific research question [7]. Scoping reviews have become popular research methods serving as an alternative to a systematic review [7]. The scoping review is considered scientifically rigorous and includes a series of stages to follow that are especially ideal for a stand-alone project or for a preliminary review where there is little known about a particular subject or paradigm [7].
This scoping review followed the foundational structure and frameworks highlighted by Arksey & O'Malley [8]. They include five steps delineated below.
This scoping review contains three primary research objectives aimed at synthesizing relevant literature on interventions that have an impact on Black/African Americans affected by adverse childhood experiences:
Objective 1: To qualitatively examine, compare, and contrast the literature.
Objective 2: To provide a narrative summary of each intervention identified in the search.
Objective 3: To identify gaps in the literature.
The literature search was conducted between December 2022 and January 2023 using four social science databases. They include the Social Work Abstracts (EBSCO), PsychInfo (ProQuest), Applied Social Sciences Index and Abstracts (ASSIA) (ProQuest), and the Social Services Abstracts (ProQuest). The searches focused on finding interventions targeting the impacts of adverse childhood experiences among Black/African American adults.
Search terms were selected based on common synonyms found in the Sociological Abstracts (ProQuest). Articles containing languages outside of a Western English dialect were excluded due to the inability to translate and for syntax clarity. The following keywords were searched both separately and in various combinations.
• For the condition/experiences being examined, the terms included: “adverse childhood experiences” OR “childhood trauma*” OR “childhood adversity*” OR “child*divorce” OR “child* sex abuse” OR “adolescent trauma” OR “childhood neglect” OR “child*poverty”
• For racial/ethnic identity terms, the keywords searched included the following: “Black American*” OR “African American” OR “Black” OR “Black/African American”
• Intervention search terms included the following: “intervention*” OR “therap*” OR “treat*” OR “prevention*” OR “counsel* OR “psychotherap*” OR “group work” OR “family work” OR “direct practice” OR “program*” OR “service*” OR “strateg*” OR “technique*”
• The target population keyword search terms were “adult*” OR “adolescent*” OR “youth*” OR “teenager” OR “young adult” OR “young adult” OR “youth”
This stage provides the foundation for the selection process of literature for the study. Arksey and O’Malley [8] refer to this step as the “mechanism to help us eliminate studies that did not address our central research question” (p. 25). Despite this study not taking the form of a systematic review, inclusion and exclusion criteria were still needed to narrow the 784 studies selected for screening. The following criteria were used.
This study only included published material from the United States within the past ten years. Studies included must have had at least 25% of participants identified as Black/African American adults. The study had to entail an intervention directly applied to the identified population. All of the articles were studies. No thesis, dissertations, books, or reports were included.
This study did not include foreign language material and studies published outside of the United States. Interventions focusing on children and adolescents were excluded as the aim is to focus on the adult population. Search limits included scholarly material published within the past ten years. Secondary data analyses and conceptual papers were also excluded.
The search identified 1,146 relevant studies according to the search criteria. Of these, 784 were screened as meeting all or some of the inclusion criteria. The final assessment left 6 studies as fully meeting all the inclusion criteria (Figure 1). The studies were organized in a uniform approach based on the Arksey and O’Malley [8] framework. This included the author(s) name, year of publication, the type of intervention, the sample demographics (i.e. age, race, and location), the purpose of the study, the reported outcomes, and results.
An overview of the interventions is summarized below. This scoping review does not seek to infer intervention effectiveness, nor does it determine the generalizability of findings. In addition to the intervention summaries below, Table 1 maps the geographical content, the scope of the interventions, and the measurement tools used. The content of the summaries and Table was adopted from Arksey and O'Malley [8].
Allen et al. [9] conducted a study in Los Angeles, California regarding the impact of an intervention for chronic depression among Black/African American men who were engaging in risky sexual behavior. The participants were Black men who had sex with men and women (MSMW). The study identifies all the participants as 18 and above with the average age being 46 years old. All participants were screened for adverse childhood experiences and all of them reported having a history of childhood sexual abuse. Additionally, the participants reported other ACE impacts such as unemployment, having only a high school education or less, and having a low income. The study reported that “men’s childhood sexual abuse was predictive of adult depression” (p. 130). One hundred seventeen men participated in the study.
Few details were provided about the structure of the intervention or those who facilitated the program. The intervention was a six session program designed to address sexually risky behavior and to reduce chronic stress and depression. The results showed that a combination of perceived social supports and the intervention had some effect on depressive symptom levels. Allen et al. [9] said “these findings suggest that the level of perceived social support reported by participants significantly moderated the detrimental effects of discrimination and chronic stress on depressive symptoms” (p. 132).
A pilot study aimed to reduce the symptoms of adverse childhood experiences by applying brief intervention therapy and parental support to parents/caregivers with ACEs [10]. The study was conducted in the Cincinnati, Ohio area and the majority (51%) of participants self-identified as Black/African American. The average age of the participants was 32 years old. The majority of the participants self-identified as female and not married. One hundred fifty people participated in the study of which 60% reported having at least one ACE. Twenty-three percent of the participants reported an ACE score of three or more.
The intervention is called Strengthening Families. It used a multi pronged approach utilizing evidence-based motivational interviewing and adversity screening techniques to promote family wellness. The researchers hypothesized that increasing the caregivers’ protective factors would enable them to develop greater resilience to parental stress and their own ACE triggers, with the goal of reducing future ACE impacts on both their children and their own adult lives. Each parent/caregiver was paired with a childcare provider of a local agency along with a clinical research team member and a life coach. This team provided five weekly sessions addressing resilience, self-care, parenting approaches, and strengthening the parent–child relationship. In addition, the parents/caregivers were also provided a two-hour training session on the effects of ACEs and how stress impacts the brain. Eismann et al., [10] found that parents who completed the entire intervention reported increases in their protective factors. The factors were identified as family resilience, social support, concrete support, nurturing, and attachment. The researchers believe that increased protective factors have a positive impact on adversity: “These findings reinforce our approach to promote family protective factors and resilience in an effort to counterbalance and reduce the risk for adversity” (p. 454).
Goldstein et al. [12] conducted a pilot study utilizing a structured interviewing technique based on the Health Belief Model. The study identified this model as a tool to stimulate behavior change when participants are aware of potential negative outcomes of their behavior. The study took place in Milwaukee, Wisconsin. Forty people participated in the intervention. All 40 endorsed at least one ACE. The majority (76%) of participants self-identified as Black/ African American with an age range between 18 and 49. The mean age was 43. Study researchers reported that “prolonged exposure to adversity in marginalized communities often extends into adulthood” (p. 187). Therefore, researchers sought to explore the benefits of a structured interviewing technique with the objective of lowering stress rates and increasing the resilience of the participants.
All the participants were screened for ACEs followed by the delivery of two structured interview sessions led by mental health therapists. Both sessions included elements of efficacy promotion and strengths based motivational interviewing. Findings were brief and limited and were presented qualitatively. Following the intervention, participants were able to identify negative coping strategies such as risky sexual behavior, poor nutrition, and unhealthy substance use. Some of the positive outcomes recognized by the patients were deriving pleasure from engaging in target behaviors such as healthy coping skills and optimism in making healthy lifestyle changes.
A six-week group intervention pilot study based in Minneapolis, Minnesota was reported by Miller et al. [13]. Twenty-six self identified Black/African American males between the ages of 18 and 62 participated. The average age was 37. Most of the study participants resided in the North Minneapolis, Minnesota area. The macro goal of the study was to reduce the transmission rates of trauma in Black/African American communities.
The intervention focused on tailoring motivational interviewing techniques with the inclusion of Black/African American cultural features built into it. The intervention is called Choosing Life in the Black Community: Achieving the Dream. This Afrocentric intervention utilized cognitive behavioral therapy with features of Black American culture and history including parts of African history from the ancient Kemet society to the Civil Rights era. The objective was to infuse cultural heritage into the therapy sessions to stimulate meaningful conversation with the overall goal of improving the intervention’s effectiveness. One of the targeted outcomes of the intervention was to learn a “breathing practice aimed at learning to manage feelings around trauma or stress” (p. 714). The study reported reductions in PTSD (post-traumatic stress disorder) symptoms as well as an increase in collective efficacy rates.
Santa Maria et al. [14] conducted a randomized control trial utilizing mobile messages to reduce risky sexual behavior among youth experiencing homelessness. The participants were aged 18 25. Ninety-seven youths participated in the study. The setting was Houston, Texas. Sixty-five percent of the participants self-identified as Black/African American. Each of the participants completed a survey and an assessment including a history of childhood trauma and foster/juvenile engagement. The researchers described the participants as engaging in high-risk HIV behaviors including, but not limited to, unprotected sex, substance abuse during condomless sexual intercourse, and men having sex with men (MSM). Santa Maria et al. [14] reported that this is a “hard-to-reach population” and that they often “lack the motivation to engage in an intervention” (p. 9).
The risk reduction intervention is labeled as Ecological Momentary Assessment. It entailed a six-week program where the research staff designed a mobile phone interface system prompting the participants two to three times a day for six weeks. The participants received messages directing them to their behavior goals based on their culture and environment. Findings indicated that the mobile phone intervention increased motivation to practice safer sexual engagement with reduced alcohol use. Santa Maria et al. [14] said, “the findings from this study suggest a positive effect of a highly scalable mobile intervention that increases access to an HIV prevention intervention for a hard-to-reach population” (p. 12).
Senn et al. [15] describe a pilot randomized control trial with the objective of reducing risky sexual behaviors among adult women identified as having experienced childhood sexual abuse. Eighty-four adult women participated in this intervention. All study participants reported a history of childhood sexual abuse and current risky sexual behavior including condomless sex with multiple partners within a three-month period. The average age was 30.5 with 68% of the participants identifying as Black/African American. The specific location of the intervention was not disclosed but rather described as a social services research clinic in a socio-economically disadvantaged urban area.
The intervention was a group design based on the following two models: Information-Motivation-Behavioral Skills (IMB) and Traumagenic Dynamics (TD) framework. The researchers identified these models as frameworks to engage the participants’ motivation in choosing safer sexual practices as well as other risk-reduction behaviors. Participants were guided through five, two-hour groups by a licensed, female marriage and family therapist using the above described models. The study included a follow-up survey after three months. Findings suggested that the intervention addressing the effects of childhood sexual abuse had an impact on the reduction of risky sexual behavior among the participants.
This scoping review examined psychosocial interventions to reduce the effects of adverse childhood experiences among Black/African American adults. Overall, this analysis found that psychosocial and psychoeducation-based interventions positively affected the reduction of ACE-related symptoms. Nevertheless, it is difficult to develop intervention themes as there is tremendous variation in the intervention designs, execution, location, and methods. The interventions appear harmonious only in the common concept that trauma in childhood is connected to a myriad of impairments in later adult functioning.
There was a good mix of study locations. Mostly large, urban areas were represented in the studies with a few located in smaller midwestern regions. Effect sizes and methodological rigor are not assessed in a scoping review [8]. However, it is worth highlighting that two of the six studies [14,15] were randomized control trials providing the highest level of rigor.
The majority of the studies (67%) had large sample sizes of 80 participants and above. All the studies included the use of ACE measurement and screening tools; however, the type of tools and how they were administered varied across each study. Reidy et al. [16] mention that there are over 20 different versions of the original ACE screening tools being utilized and that this lack of uniformity diminishes study effectiveness and generalizability.
The harmful impacts of adverse childhood experiences have been discussed throughout this paper. The literature has also indicated that Black/African Americans have a disproportionally higher incidence of ACEs than other U.S. based racial/ethnic groups. Ultimately, this is a social problem for many reasons, one being that the harmful effects of ACEs eventually cause tremendous negative health and economic effects in adult life. Social workers can play an instrumental role in mitigating these effects. First, social workers can continue actively searching, developing, testing, and eventually implementing interventions that reduce the harmful effects of ACEs. Social workers can also educate their clients about ACEs and utilize screening assessment tools to identify patients that are most at risk.
The Preamble of the National Association of Social Workers [17] refers to social workers’ engagement with organizations, communities, and other social institutions to respond to the needs of people and social problems [17]. Researching, testing, and developing effective interventions is one method of serving in the above capacity. The Council on Social Work Education (CSWE) adds to this point. One of its principal aims is to impact health care through its policy initiative on behavioral and social science research. The CSWE’s 2016-2020 Strategic Plan includes using its platform to expand healthcare-related technologies, education, and research to “traditionally underrepresented populations in research and access to care” [18]. The scope of this study aligns agreeably with this initiative.
Ultimately, the literature points to early detection as a major key to lessening the impacts of ACEs. Social workers can aid in this process through service in a variety of settings ranging from community based mental health organizations to hospitals, prisons, jails, schools, research settings, and more.
This scoping review has several limitations. First, the population studied is very narrow. It focused on Black/African American adults from a small number of national studies found. The second limitation is that this review searched for interventions that were psychosocial and/or behaviorally based. The impacts of adverse childhood experiences maybe better treated holistically from a medical approach combined with psychosocial interventions. Srivastav et al. [2] suggest that the socio-ecological model supports the need to address public health by targeting all the social determinants of health as opposed to just one selected aspect.
Another limitation is the limited data collection and reporting in the included studies. As mentioned earlier, there were only two randomized control trials that provided adequate quantitative data. A scoping review does not concentrate on such outcomes. A quantitative synthesis should be undertaken when more studies are available. Furthermore, as similarly noted by other ACE researchers, “the lack of psychometric data also raises significant questions about the validity, generalizability, and quality of each study” [19].
This study is also limited by the absence of examination of the varying cultural aspects that impact outcomes related to adverse childhood experiences. Future research should include these varying cultural components. The ACEs screening tools and corresponding interventions would benefit from being culturally tailored to the racial/ethnic group(s) they are used with, as “specific knowledge of minority communities’ culture and history is crucial to the cross cultural clinical encounter”[20].
The impact of adverse childhood experiences has become an epidemic in American society as approximately 60% of the U.S. population is reported as having experienced at least one [21]. The rates are disproportionally higher for Black/African Americans ultimately affecting their health and social mobility. ACEs are a threat to societal and economic productivity. These systems impact employment longevity, and the ability to generate sustainable income which in turn affects national economic strength.
The need for continued research in developing effective, evidence based interventions to address ACEs for this population is warranted. Six studies out of a nationwide search of over one thousand articles is hardly sufficient to address a public health problem of this magnitude. This scoping review has shown that there is a dearth of research on the development, implementation, and evaluation of an array of interventions that are both culturally appropriate and geographically specific. Culturally-tailored or culturally-based intervention research is critical to address racial or ethnic discrimination related to health care access and disparities [22].
Fundamentally, Black/African Americans carry a plethora of cultural differences that have shown to be a stumbling block in both seeking and receiving effective prevention and intervention for ACEs. Evans et al. [23] reported that “the literature reviews of early intervention services suggest that services to minority families are often culturally inappropriate, resulting in a lack of suitable services” (p. 98). Social workers have cultural competency training as part of their professional development. This training can be utilized to develop culturally appropriate interventions for this population.
To conclude, this scoping review mapped the evidence on interventions to mitigate ACE-related impacts among the Black/ African American adult population. The study highlighted limited evidence of interventions specifically addressing this population. The evidence presented in these studies suggests a positive impact of the interventions on the ACE symptoms identified. However, the rigor of the few existing studies is limited. The Black/African American community will benefit from the development of RCTs on culturally appropriate interventions to combat the damaging effects of adverse childhood experiences.
The authors declare that they have no competing interests.
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